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<h1>FORMULAIRE D\'INSCRIPTION POUR L\'ANNEE 2013-2014</h1><br><br>

<form action="action_formulaire.php" method="POST">
     <fieldset class="eleve">
          <legend>ELEVE</legend>
				<label for="nom">Nom</label>
				<span class="marge"><input type="text" name="nome" required/></span><br>
				<label for="prenom">Pr&eacute;nom </label>
				<span class="marge"><input type="text"name="prenome" required/></span><br>
				<label for="date-de-naissance">Date de naissance</label>
				<span class="marge"><input type="date" name="date-de-naissance" required/></span><br>
     </fieldset><br><br>
	 
     <fieldset class="responsable">
          <legend>RESPONSABLE</legend>
				<label>Nom</label>
				<span class="marge"><input type="text" name="nomresp" required/></span><br>
				<label>Pr&eacute;nom</label>
				<span class="marge"><input type="text" name="prenomresp" required/></span><br>
				<label>Adresse</label>
				<span class="marge"><input type="text" name="adresse" required/></span><br>
				<label>Code postal</label>
				<span class="marge"><input type="text" name="code-postal" required/></span><br>
				<label>Ville</label>
				<span class="marge"><input type="text" name="ville" required/></span><br>
				<label>Tel fixe</label>
				<span class="marge"><input type="text" name="fixeresp" required/></span><br>
				<label>Tel portable</label>
				<span class="marge"><input type="text" name="portableresp" required/></span><br>
     </fieldset><br><br>
	 
	 <fieldset class="cours"> 
			<legend>COURS CHOISI(S)</legend><br><br>  
					<INPUT type="checkbox" name="choix" value="eveil" checked> Eveil
					<INPUT type="checkbox" name="choix" value="initiation"> Initiation
					<INPUT type="checkbox" name="choix" value="classique"> Classique
					<INPUT type="checkbox" name="choix" value="modern jazz"> Modern Jazz
					<INPUT type="checkbox" name="choix" value="contemporain"> Contemporain
					<INPUT type="checkbox" name="choix" value="hiphop"> Hip-hop
						<br/><br/><label>Niveau :</label>
						<select name="niveau">
						<option>D&eacute;butant(e)</option>
						<option>Correct</option>
						<option>Avanc&eacute;</option>
						</select><br /><br />
	 </fieldset><br /><br />

	 <fieldset class="urgence">
          <legend>PERSONNE A CONTACTER EN CAS D\'URGENCE</legend>
		  <p>Si diff&eacute;rente du responsable !</p>
				<label for="nom">Nom</label>
				<span class="marge"><input type="text" name="nomurg" /></span><br>
				<label for="prenom">Pr&eacute;nom </label>
				<span class="marge"><input type="text" name="prenomurg" /></span><br>
				<label>Tel fixe</label>
				<span class="marge"><input type="text" name="fixeurg" /></span><br>
				<label>Tel portable</label>
				<span class="marge"><input type="text" name="portableurg" /></span><br>
     </fieldset><br><br>

	 <fieldset class="mail"> 
			<legend>Adresse Mail (OBLIGATOIRE)</legend><br><br>
				Une adresse mail (&eacute;l&egrave;ve ou responsable) est requise pour valider l\'inscription !<br><br>
				<label> e-mail :</label>
				<input type="email" name="mail" required/><br /><br />	
	 </fieldset><br /><br />
	 
		<article>
			<h2>IMPORTANT</h2>
			<br>Un certificat m&eacute;dical de moins de trois mois est obligatoire (&agrave; pr&eacute;senter au 1er cours).</br>
			Acceptez-vous la publication de photos de votre enfant dans des communications locales, 
			r&eacute;alis&eacute;es dans le cadre des activit&eacute;s de l\'Ecole de Danse de Beaucouz&eacute; ?<br><br> 
			OUI <INPUT type="radio" name="photo" value="oui" checked>
			NON <INPUT type="radio" name="photo" value="non"><br>
			<br><INPUT type="checkbox" name="choix1" value="1" required> Je soussign&eacute;(e) d&eacute;clare avoir pris connaissance du R&egrave;glement int&eacute;rieur de l\'Ecole de Danse de Beaucouz&eacute; et accepte toutes 
			les conditions.</br> 
		</article>

			<br><input style="padding: 5px; color: white; font-weight: bold; background:#FF8C00; " type="submit" name="ajouter" value="Ajouter"/>
			<input style="padding: 5px; color: white; font-weight: bold; background:#FF8C00; " type="reset" name="annuler" value="Annuler"/>
			
			<form method="post" action="connexion_reussie.php">
			<input style="padding: 5px; color: white; font-weight: bold; background:#FF8C00; " type="submit" name="retouraumenu" value="Retourner au menu"/>
			</form><br>
</form>			
</div>
	</div>
  <p>&nbsp;</p>

		
	</div>';
	$site->affiche();
?>

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